Patient Health And History Form

*Due to the current pandemic, VisionSource is taking every effort to insure your safety, as well as staff safety. By utilizing this privacy protected document, we will be protecting you from extended chair and office time, in turn reducing your potential exposure risk.*

Patient Name

Date

Please list the date of your last eye exam

Date

Reason for Visit

List all specific concern(s) to inform your Doctor (blurred vision, red eye, itching, etc)

Answer all that apply to your above reason for visit:

Location; Which Eye?

How long have you been experiencing this?

Is this a new concern?

Consistent or Intermittent?

Consistent Intermittent Not Applicable

If intermittent, how often?

Mild , Moderate or Severe?

Mild Moderate Severe

If pain, how does it feel?

Dull

Stabbing

Ache

Any known cause?

What makes it better? Worse?

Any other Symptoms?

Please Notate if You Have Been Diagnosed With or Experience the Following:

Diabetic?

Yes No

If yes, Type 1 or 2?

Type 1 Type 2

Date Diagnosed

A1C

Name of Doctor Managing Diabetes

Phone Number

Doctor’s Address

Retinal Problems?

Yes No

If yes, Diagnosis?

Date

Glaucoma?

Yes No

If yes, taking eye drops?

Date

Macular Degeneration?

Yes No

If yes, taking vitamins?

Date

Night Vision Concerns?

Yes No

If yes, how long?

Worsening?

Yes No

Dry Eye Concerns?

Yes No

If yes, how long?

Worsening?

Yes No

Review of Systems

Please Mark Any Health Condition You Have Been Diagnosed With:

Cancer

Hearing Loss

Sinusitis

Multiple Sclerosis

Epilepsy

Cerebral Palsy

Tumor

Stroke/CVA

Migraine

Autism Spectrum Disorder

Depression

Attention Deficit

Anxiety Disorder

Bipolar Disorder

Hypertension

Heart Disease

Vascular Disease

Congestive Heart Failure

Asthma

Bronchitis

Emphysema

Sleep Apnea

Chron’s Disease

Colitis

Ulcer

Acid Reflux

Celiac Disease

Kidney Disease

Prostate Disease/Cancer

STD- herpetic/chlamydia

Prostate Hypertrophy

Pregnant

Nursing

If pregnant, how many months?

Osteoarthritis

Arthritis

Fibromyalgia

Muscular Dystrophy

Osteoporosis

Gout

Eczema

Rosacea

Psoriasis

Cold Sores

Shingles

Diabetes

Diabetes Type

Thyroid Dysfunction

Hormonal Dysfunction

Anemia

High Cholesterol

Rheumatoid Arthritis

Lupus

Sjogren’s Syndrome

Other

If Other, please specify

Prescription Medications & Allergies

Please List All CURRENT Prescription Medication and/or Eye Drops (Include strength and frequency)

Add new row

Please List All Medication ALLERGIES

Add new row

Other Allergies

List All Other Allergies or Latex Sensitivity (Seasonal, Pollen, Hay Fever, Dust, Foods)

Add new row

Personal Ocular & Social History

List All Ocular Injuries, Surgeries, Diagnosis and Dates

Add new row

Answer the Following Questions About Your Social History

Tobacco Use?

Yes No

Past History

Yes No

If Yes, type?

How much?

Alcohol Use?

Yes No

How often?

Family Ocular and Systemic History

Please Notate Family Members Diagnosed with the Following Conditions (Father, Mother, Brother, Sister, Grandparent)

Cancer

Family Member

Father

Mother

Brother

Sister

Grandparent

Hypertension

Family Member

Father

Mother

Brother

Sister

Grandparent

High Cholesterol

Family Member

Father

Mother

Brother

Sister

Grandparent

Diabetes

Family Member

Father

Mother

Brother

Sister

Grandparent

Hyperthyroid

Family Member

Father

Mother

Brother

Sister

Grandparent

Hypothyroid

Family Member

Father

Mother

Brother

Sister

Grandparent

Macular Degeneration

Family Member

Father

Mother

Brother

Sister

Grandparent

Glaucoma

Family Member

Father

Mother

Brother

Sister

Grandparent

Retinal Disorders

Family Member

Father

Mother

Brother

Sister

Grandparent

Other

Family Member

Father

Mother

Brother

Sister

Grandparent

Other

Family Member

Father

Mother

Brother

Sister

Grandparent

Other

Family Member

Father

Mother

Brother

Sister

Grandparent

If you are age 20 and older, please answer the questions below

1. Questions about EYE DISCOMFORT:

a. During a typical day in the past month, how often did your eyes feel discomfort?

Select the option below that best matches your answer

Never

Rarely

Sometimes

Frequently

Constantly

b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?

Select the option below that best matches your answer

Never Have It

Not At All Intense

Somewhat Intense

Moderately Intense

Intense

2. Questions about EYE DRYNESS:

a. During a typical day in the past month, how often did your eyes feel dry?

Select the option below that best matches your answer

Never

Rarely

Sometimes

Frequently

Constantly

b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?

Select the option below that best matches your answer

Never Have It

Not Intense At All

Somewhat Intense

Moderately Intense

Intense

3. Question about WATERY EYES:

a. During a typical day in the past month, how often did your eyes look or feel excessively watery?

Select the option below that best matches your answer

Never

Rarely

Sometimes

Frequently

Constantly

Contact Lens History

Please Answer Questions Regarding Contacts Lenses If Applicable

Contact Lens Brand

Overnight Wear?

Replacement Schedule?

Hour usage per day?

Concerns?

Comfortable?

Other?

Your information will be encrypted.

Patient Health And History Form

Reason for Visit

Answer all that apply to your above reason for visit:

Please Notate if You Have Been Diagnosed With or Experience the Following:

Review of Systems

Please Mark Any Health Condition You Have Been Diagnosed With:

Prescription Medications & Allergies

Please List All CURRENT Prescription Medication and/or Eye Drops (Include strength and frequency)

Please List All Medication ALLERGIES

Other Allergies

List All Other Allergies or Latex Sensitivity (Seasonal, Pollen, Hay Fever, Dust, Foods)

Personal Ocular & Social History

List All Ocular Injuries, Surgeries, Diagnosis and Dates

Answer the Following Questions About Your Social History

Family Ocular and Systemic History

Please Notate Family Members Diagnosed with the Following Conditions (Father, Mother, Brother, Sister, Grandparent)

If you are age 20 and older, please answer the questions below

Contact Lens History

Please Answer Questions Regarding Contacts Lenses If Applicable

The Vision Source-Kingwood, P.A.